Cervical musculoskeletal impairment is common in elders with headache

There is an opinion that with increasing cervical degenerative joint disease with ageing, cervicogenic headaches become more frequent. This study aimed to determine if cervical musculoskeletal dysfunction was specific to headache classifiable as cervicogenic or was more generic to headache in elders. Subjects (n = 118), aged 60–75 years with recurrent headache and 44 controls were recruited. Neck function measures included range of motion (ROM), cervical joint dysfunction, cranio-cervical flexor muscle function, joint position sense (JPS) and cervical muscle strength. A questionnaire documented the characteristics of headaches for classification. A cluster analysis based on three musculoskeletal variables aligned previously with cervicogenic headache, divided headache subjects into two groups; cluster 1 (n = 57), cluster 2 (n = 50). Dysfunctions were greater in cluster 1 than in 2 for extension range and C1–2 joint dysfunction (p < 0.05). Most cervicogenic headaches were grouped in cluster 1, but musculoskeletal dysfunction was also found in headaches classifiable as migraine or tension-type headache. Neck dysfunction is not uniquely confined to cervicogenic headache in elders. Further research such as headache responsiveness to management of the neck disorder is required to better understand about the neck's causative or contributing role to elders' headache.     

Cervical musculoskeletal impairment in frequent intermittent headache. Part 2: subjects with concurrent headache types

A pattern of musculoskeletal impairment inclusive of upper cervical joint dysfunction, combined with restricted cervical motion and impairment in muscle function, has been shown to differentiate cervicogenic headache from migraine and tension-type headache when reported as single headaches. It was questioned whether this pattern of cervical musculoskeletal impairment could discriminate a cervicogenic headache as one type of headache in more complex situations when persons report two or more headaches. Subjects with two or more concurrent frequent intermittent headache types (n = 108) and 57 non-headache control subjects were assessed using a set of physical measures for the cervical musculoskeletal system. Discriminant and cluster analyses revealed that 36 subjects had the pattern of musculoskeletal impairment consistent with cervicogenic headache. Isolated features of physical impairment, e.g. range of movement (cervical extension), were not helpful in differentiating cervicogenic headache. There were no differences in measures of cervical musculoskeletal impairment undertaken in this study between control subjects and those classified with non-cervicogenic headaches.     

Reliability of Manual Mobility Testing of the Upper Cervical Spine in Subjects with Cervicogenic Headache

Abstract

The identification of a cervicogenic headache is determined by criteria as stated by the International Headache Society (IHS). One of the criteria involves a finding of abnormal tenderness or resistance to movement in the neck region. The purpose of this study was to examine the inter-examiner and intra-examiner reliability of manual mobility testing of the upper cervical spine in the diagnosis of cervicogenic headaches in symptomatic subjects. Two groups of 20 subjects were required to meet initial criteria for a cervicogenic headache as adapted from the IHS. Subjects were not currently receiving medical treatment for headaches. To determine inter-examiner reliability, two examiners independently examined the 20 subjects (ages 22-48; 5 males and 15 females). Each examiner performed 15 mobility tests in random order on each subject. To establish intra-examiner reliability, a separate group of 20 subjects (ages 21-48; 3 males and 17 females) was evaluated by one examiner on two consecutive days. The Spearman's rho correlation was applied to the total number of abnormal findings recorded across each group of subjects. The Kappa correlation coefficient and percent agreement were used to compare the findings of each of the 15 mobility tests. They were also used to compare the identification of at least one abnormal finding for every subject. For this study, Kappa values ≥0.400 were considered acceptable. The Spearman's rho value for inter-examiner reliability was 0.943. Acceptable inter-examiner reliability was found on 11 out of 15 mobility tests, with Kappa values ranging from –0.053 to 1.000 and percent agreement values ranging from 70 to 100%. There was 100% agreement between examiners on whether the subject met the IHS criteria, resulting in a Kappa value of 1.000. The Spearman's rho value for intra-examiner reliability was also 0.943. Kappa values for intra-examiner reliability were acceptable for 11 out 15 tests and ranged from 0.208 to 1.000. The percent agreement values ranged from 60 to 100%. There was 100% agreement on consecutive days on whether the subject met the IHS criteria, yielding a Kappa value of 1.000. This study found that mobility testing, which includes palpation of the cervical spine, is a reliable tool, specifically in the identification of a cervicogenic headache in symptomatic subjects.     

Management of cervical headache

SUMMARY. The success of physical therapies in the management of headache relies in the first instance on an accurate differential diagnosis of a cervical musculoskeletal origin to the headache. Examination should identify a symptomatic pattern of headache characteristic of neck dysfunction and these symptoms must be associated with relevant physical impairments in the cervical articular and muscle systems. Dysfunction in the upper three cervical joints, poor activation levels and endurance capacity of the deep and postural supporting muscles of the neck, shoulder girdle region and deficits in kinesthesia have been identified in the cervical headache patient. Treatment needs to be precise and comprehensive to address each aspect of this interrelated dysfunction if long-term success of treatment is to be achieved.     

Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single headaches

Musculoskeletal disorders are considered the underlying cause of cervicogenic headache, but neck pain is commonly associated with migraine and tension-type headaches. This study tested musculoskeletal function in these headache types. From a group of 196 community-based volunteers with headache, 73 had a single headache classifiable as migraine (n = 22), tension-type (n = 33) or cervicogenic headache (n = 18); 57 subjects acted as controls. Range of movement, manual examination of cervical segments, cervical flexor and extensor strength, the cranio-cervical flexion test (CCFT), cross-sectional area of selected extensor muscles at C2 (ultrasound imaging) and cervical kinaesthetic sense were measured by a blinded examiner. In all but one measure (kinaesthetic sense), the cervicogenic headache group were significantly different from the migraine, tension-type headache and control groups (all P < 0.001). A discriminant function analysis revealed that collectively, restricted movement, in association with palpable upper cervical joint dysfunction and impairment in the CCFT, had 100% sensitivity and 94% specificity to identify cervicogenic headache. There was no evidence that the cervical musculoskeletal impairments assessed in this study were present in the migraine and tension-type headache groups. Further research is required to validate the predictive capacity of this pattern of impairment to differentially diagnose cervicogenic headache.     

Possible Identification of Cervicogenic Headache Among Patients With Migraine: An Analysis of 374 Headaches

According to Sjaastad, the pain in cervicogenic headache, a form not recognized by the IHS, is long lasting and always side-locked unilateral. The frequency of side-locked unilateral pain (defined here as no change in side from onset) and other characteristics of cervicogenic headache were investigated in 300 outpatients using information collected on standard forms in structured interviews. Three hundred seventy-four headaches diagnosed according to IHS criteria were identified. Three hundred forty-eight of these headaches were long-lasting (duration of more than 4 hours); migraine (65%) followed by tension-type headache (25%) were the commonest forms. Side-locked unilaterality was present in 29% (101 of 348), and occurred most frequently in migrainous disorders not fulfilling the criteria (25 of 56, 44.6%). This group differed significantly from the other migraine conditions for longer pain duration ( P <0.02) and less frequent nausea, vomiting, photophobia, phonophobia ( P <0.0001), and aggravation by physical activity ( P <0.02). With these characteristics, this group resembled cervicogenic headache. However, in none of these patients was pain triggered by head or neck movements, and the frequency of head or neck trauma did not differ from other headaches. A more precise definition of clinical criteria for cervicogenic headache vs migraine is, therefore, required.     

Abstracts of Current Literature

Abstract

The objective of our study was to determine the effectiveness of manual therapy for balancing C1 and a home exercise program, including active neck retraction exercises performed in a series of progressions, in the treatment of cervicogenic headache. The subjects included a 42-year-old male (Subject 1) and a 25-year-old female (Subject 2), both with a primary complaint of right-side suboccipital headache. Subject 1 was functionally limited in reading, sleeping, and playing basketball. Subject 2 reported problems with working, sleeping, and running on a treadmill. Both subjects met the criteria for cervicogenic headache as adapted from the International Headache Society. On Day 1, each subject completed three self-report measures: a numeric pain scale for both worst and average headache pain as well as the Patient Specific Functional Scale. Each subject was treated on Days 1, 3, and 5. Intervention included using a muscle energy technique for balancing C1 and a home program consisting of a progression of McKenzie's retraction/extension/rotation exercises. Each subject was told he/she may continue the home program on his/her own accord every 2 hours or as a headache occurred. On days 12 and 26, each subject completed the previous three self-report measures as well as the Global Rating Scale during blinded follow-up phone visits. The subjects demonstrated an increase in functional activities, a decrease in average and worst headache pain, and an overall improvement in their perception of change in the headache. Manual therapy in addition to a home program of active neck retraction exercises in a series of progressions was successful in relieving cervicogenic headache and improving function in two subjects. Patients with cervicogenic headaches could be empowered to alleviate their own symptoms with decreased physical therapy visits and decreased cost by having a manual therapy technique performed on them followed by a home exercise program.     

Clinical tests of musculoskeletal dysfunction in the diagnosis of cervicogenic headache

Persistent intermittent headache is a common disorder and is often accompanied by neck aching or stiffness, which could infer a cervical contribution to headache. However, the incidence of cervicogenic headache is estimated to be 14-18% of all chronic headaches, highlighting the need for clear criterion of cervical musculoskeletal impairment to identify cervicogenic headache sufferers who may benefit from treatments such as manual therapy. This study examined the presence of cervical musculoskeletal impairment in 77 subjects, 27 with cervicogenic headache, 25 with migraine with aura and 25 control subjects. Assessments included a photographic measure of posture, range of movement, cervical manual examination, pressure pain thresholds, muscle length, performance in the cranio-cervical flexion test and cervical kinaesthetic sense. The results indicated that when compared to the migraine with aura and control groups who scored similarly in the tests, the cervicogenic headache group had less range of cervical flexion/extension (P=0.048) and significantly higher incidences of painful upper cervical joint dysfunction assessed by manual examination (all P<0.05) and muscle tightness (P<0.05). Sternocleidomastoid normalized EMG values were higher in the latter three stages of the cranio-cervical flexion test although they failed to reach significance. There were no between group differences for other measures. A discriminant analysis revealed that manual examination could discriminate the cervicogenic headache group from the other subjects (migraine with aura and control subjects combined) with an 80% sensitivity.     

Neck Mobility in Different Headache Disorders

The main purpose of this study was to assess neck mobility (by Cybex equipment) in different headache disordered and, in particular, cervicogenic headache, and to compare; these findings with those in controls. A total of 51 control subjects and 90 headache patients were investigated, whereof 28 patients suffered from common migraine (migraine without aura), 34 from tension-type headache (H episodic and 25 chronic), and 28 patients from cervicogenic headache. One-way ANOVA and post hoc Bonferroni analysis showed significant differences between those with cervicogenic headache and the other groups for rotation ( P <0.001) and flexion/extension ( P <0.001), but not for lateral neck movement ( P =NS). There were no significant differences between migraine patients, tension-type headache patients, and controls. In all four groups, there was a significant positive correlation between active and passive neck movement for rotation ( P <0.001), flexion/extension ( P <0.001), and lateral neck movement ( P <0.001). Repeated measures analysis of variance (ANOVA) showed no significant day-to-day differences in 10 control subjects. In the control group (n=51), there was a significant negative correlation between age and neck movement. For rotation. Pearson's correlation coefficient was: r =-0.71 ( P <0.001), for flexion/extension r =-0.71 ( P <0.001), and for lateral neck movement r =-0.67 ( P <0.001). No significant sex difference was found as for any of the neck movements. Pain at the time of investigation did not seem to influence neck mobility. Cervicogenic headache has been recognized as a pair syndrome by the International Association for the Study of Pain (IASP). Since reduced neck mobility is one of the major criteria for this diagnosis, it emphasizes the need for systematic, objective neck mobility measurements in the individual patient to substantiate the diagnosis. The technique is simple and proved reliable.     

Physical impairments in cervicogenic headache: traumatic vs. nontraumatic onset

In order to quantify the physical impairments associated with different types of headache, 77 subjects belonging to four different groups (postmotor vehicle accident cervicogenic headache subjects, cervicogenic headache subjects nontraumatic, migraine patients and control subjects) were evaluated using the following variables: posture, cervical range of motion, strength of the neck flexors and extensors, endurance of the short neck flexors, manual segmental mobility, proprioception of the neck, and pain (McGill Pain Questionnaire and the skin roll test). The results of this study showed that postmotor vehicle accident cervicogenic patients have significantly limited active cervical range of motion (in flexion/extension and rotations), present decreased strength and endurance of neck flexors and decreased strength of the extensor muscles. Our results suggest that there are enough differences between the postmotor vehicle accident and nontraumatic cervicogenic headache subjects to warrant caution when analysing the data of these two subgroups together, as several studies have done in the past. The onset of headache is therefore an important variable that should be controlled for when attempting to characterize the physical impairments associated with cervicogenic headache.     

Clinical reasoning for manual therapy management of tension type and cervicogenic headache

In recent years, there has been an increasing knowledge in the pathogenesis and better management of chronic headaches. Current scientific evidence supports the role of manual therapies in the management of tension type and cervicogenic headache, but the results are still conflicting. These inconsistent results can be related to the fact that maybe not all manual therapies are appropriate for all types of headaches; or maybe not all patients with headache will benefit from manual therapies. There are preliminary data suggesting that patients with a lower degree of sensitization will benefit to a greater extent from manual therapies, although more studies are needed. In fact, there is evidence demonstrating the presence of peripheral and central sensitization in chronic headaches, particularly in tension type. Clinical management of patients with headache needs to extend beyond local tissue-based pathology, to incorporate strategies directed at normalizing central nervous system sensitivity. In such a scenario, this paper exposes some examples of manual therapies for tension type and cervicogenic headache, based on a nociceptive pain rationale, for modulating central nervous system hypersensitivity: trigger point therapy, joint mobilization, joint manipulation, exercise, and cognitive pain approaches.     

Cervicogenic dizziness – musculoskeletal findings before and after treatment and long-term outcome

Purpose. To explore musculoskeletal findings in patients with cervicogenic dizziness and how these findings relate to pain and dizziness. To study treatment effects and long-term symptom progress.

Method. Twenty-two patients (20 women, 2 men; mean age 37 years) with suspected cervicogenic dizziness underwent a structured physical examination before and after physiotherapy guided by the musculoskeletal findings. Questionnaires were sent to the patients six months and two years after treatment.

Results. Dorsal neck muscle tenderness and tightness was found in a majority of the patients. Zygapophyseal joint tenderness was found at all cervical levels. Cervical range of motion was equal to or larger than expected age and gender matched values. The cervico-thoracic region was often hypomobile. Most patients had postural imbalance. Dynamic stabilization capacity was reduced. Suboccipital muscles tightness correlated with posture imbalance and poor neck stability. The treatment resulted in reduced tenderness in levator scapula, high and middle paraspinal and temporalis muscles and zygapophyseal joints at C4-C7 and increased cervico-thoracic mobility. Reduction of middle paraspinal muscle tenderness correlated with neck pain relief. Postural alignment improved, as did dynamic stabilization in trunk, neck and shoulders. After 6 months, 13 of the 17 patients had still no or less neck pain and 14 had no or less dizziness. After 2 years, 7 patients had no or less neck pain and 11 no or less dizziness.

Conclusion. Patients with suspected cervicogenic dizziness have some musculoskeletal findings in common. Treatment based on these findings reduces neck pain as well as dizziness long-term but some patients might need a maintenance strategy.     

Lower cervical disc prolapse may cause cervicogenic headache: prospective study in patients undergoing surgery

In 1983 Sjaastad published for the first time diagnostic criteria for cervicogenic headache. Until now there have been no prospective studies investigating whether cervical disc prolapse can cause cervicogenic headache. Between July 2002 and July 2003 50 patients with cervical disc prolapse proven by computed tomography, myelography or magnetic resonance imaging were recruited and prospectively followed for 3 months. Patients were asked at different time points about headache and neck pain by questionnaires and structured interviews. These data were collected prior to and 7 and 90 days after surgery for the disc prolapse. Fifty patients with lumbar disc prolapse, matched for age and sex, undergoing surgery were recruited as controls. Headache and neck pain was diagnosed according to International Headache Society (IHS) criteria. Twelve of 50 patients with cervical disc prolapse reported new headache and neck pain. Seven patients (58%) fulfilled the 2004 IHS criteria for cervicogenic headache. Two of 50 patients with lumbar disc prolapse had new headaches. Their headaches did not fulfil the criteria for cervicogenic headache. One week after surgery, 8/12 patients with cervical disc prolapse and headache reported to be pain free. One patient was improved and three were unchanged. Three months after cervical prolapse surgery, seven patients were pain free, three improved and two unchanged. This prospective study shows an association of low cervical prolapse with cervicogenic headache: headache and neck pain improves or disappears in 80% of patients after surgery for the cervical disc prolapse. These results indicate that pain afferents from the lower cervical roots can converge on the cervical trigeminal nucleus and the nucleus caudalis.     

Inter-examiner reliability to detect painful upper cervical joint dysfunction

The presence of painful upper cervical joint dysfunction is a diagnostic criterion for cervicogenic headache. This preliminary study investigated whether independent examiners for a planned multicentre study of treatment of cervicogenic headache sufferers would agree on the presence or not of joint dysfunction for inclusion/exclusion of subjects into the trial. Ten subjects with or without neck pain and headache were recruited in each of four centres (total 40 subjects). Examiners manually assessed subjects' upper cervical regions in a single blind manner. There was excellent to complete agreement between each pair of examiners on which subjects should be allowed to enter the study and 70 per cent agreement between examiners on the two most dysfunctional joints in symptomatic subjects. There can be confidence that an homogenous headache group will enter the planned trial.     

The influence of lower cervical joint pain on range of motion and interpretation of the flexion–rotation test

Abstract

Objective: The purpose of this study was to investigate the impact of lower cervical facet joint pain (CFP) on the flexion–rotation test (FRT).

Methods: A single blind, comparative group design was used to investigate whether lower CFP influences FRT mobility and examiner interpretation. Twenty-four subjects were evaluated, 12 with cervicogenic headache (age 26–63 years) and 12 with lower CFP (age 44–62 years), confirmed by therapeutic cervical facet joint intervention. A single blinded examiner conducted the FRT, reporting the test state (positive or negative) before measuring range of motion using a goniometer. Subjects with lower CFP were evaluated by the FRT prior to therapeutic intervention and were excluded from analysis if they did not gain complete symptomatic relief following the procedure. Only subjects with immediate complete relief were included.

Results: The average range of unilateral rotation to the limited side during the FRT was 26 and 37.5° for the cervicogenic headache and lower CFP groups respectively. The difference between groups was significant (P<0.01). Sensitivity and specificity for cervicogenic headache diagnosis was 75 and 92% respectively. A receiver operating curve revealed that an experienced examiner using the FRT was able to make the correct diagnosis 90% of the time (P<0.01), with a positive cut-off value of 32°.

Discussion: These findings provide further evidence for the clinical utility of the FRT in cervical examination and cervicogenic headache diagnosis.     

Cervical musculoskeletal impairments in cervicogenic headache: a systematic review and a meta-analysis

Abstract

The differential diagnosis of cervicogenic headache (CEH) requires the presence of a pattern of symptoms and cervical musculoskeletal signs that distinguishes it from other types of headaches. The investigation of cervical musculoskeletal impairments (CMI) can help in the diagnosis and treatment of the CEH. In order to assess the evidence concerning CMI in CEH subjects, a systematic review and a meta-analysis was performed. Several electronic databases were searched. A checklist was used to identify suitable articles and a methodological scale was used to analyse their quality. Ten articles met the inclusion criteria. Based on our meta-analysis, patients with CEH have altered range of motion in rotation, flexion-extension, cervical rotation with cervical flexion, altered cervical flexor strength, and altered cervical flexor endurance. More controlled studies investigating the cervical impairments in CEH, with a clear history of patients, and greater sample sizes, are necessary.     

Cervicogenic Headache: The Influence of Mental Load on Pain Level and EMG of Shoulder-Neck and Facial Muscles

The relationship between pain and EMG levels was studied in 17 cervicogenic headache patients and 17 group-matched healthy controls. All subjects performed a 1-hour, complex, two-choice, reaction time test. Every 10 minutes before, during, and also for 20 minutes after the test, they reported pain levels (using visual analogue scales) in the forehead, both temples, neck, and shoulders. Electromyographic activity, using superficial electrodes, was also recorded from the frontal, temporal, neck (splenius), and trapezius muscles. Maximal voluntary contractions were performed in all the muscles.
Increased pain levels before, during, and after the test were found on the symptomatic side in the temple, shoulder area, and neck in the patient group compared with nonsymptomatic side and controls (neck only compared with controls). Electromyographic amplitudes from the trapezius muscle on the symptomatic side were significantly higher before and during the test, compared with the nonsymptomatic side, but most markedly during the test. Pretest EMG amplitudes from the frontal muscle on the symptomatic side in patients were also significantly higher than those in controls, but the difference vanished during the test. There are indications that the temporal pain, is, the headache, is a referred pain.
These observations may point to a "muscular" involvement in the pathogenesis of cervicogenic headache, either primarily or, which seems more plausible, secondarily.